On patients that I sign out AMA I always write up an addendum that says something to the effect of patient not intoxicated, not altered, everything explained in layman's terms and voiced back, pt directed to f/u PCP asap, return to ER if desires etc.

However I recently had another doc tell me that he essentially writes the above and then makes the patient sign "I understand the above instructions." and sign their name.

Anyone else going this far? I know we are never truly safe from a suit and used to think what I was doing was sufficient but this practice doesn't seem like such a bad idea.

On patients that I sign out AMA I always write up an addendum that says something to the effect of patient not intoxicated, not altered, everything explained in layman's terms and voiced back, pt directed to f/u PCP asap, return to ER if desires etc.

However I recently had another doc tell me that he essentially writes the above and then makes the patient sign "I understand the above instructions." and sign their name.

Anyone else going this far? I know we are never truly safe from a suit and used to think what I was doing was sufficient but this practice doesn't seem like such a bad idea.

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I would make sure to include in your note anything that the patient says in quotes and the manner he said it (yelling, using abusive language) any any relevent behavior (pulling off monitor leads, IV line, throwing things on the floor). Have the nurse write a note supporting your note such as statements she heard the patient make. If the patient threatens to sue I would document that in quotes as well. Document if there is any family present and that they agree with the patient signing out. If the patient is admitted, our ER docs will make that service sign the patient out. If the pt has a PCP document that they were contacted. If you are a resident, document that you notified the attending preferably before they sign AMA. I have been involved in cases like this and you see how they can rip you apart if you don't cover al bases. Basically you have to paint a picture of the patients behavior for the lawyers/judge/jury who weren't there. Hope this helps!

I would make sure to include in your note anything that the patient says in quotes and the manner he said it (yelling, using abusive language) any any relevent behavior (pulling off monitor leads, IV line, throwing things on the floor). Have the nurse write a note supporting your note such as statements she heard the patient make. If the patient threatens to sue I would document that in quotes as well. Document if there is any family present and that they agree with the patient signing out. If the patient is admitted, our ER docs will make that service sign the patient out. If the pt has a PCP document that they were contacted. If you are a resident, document that you notified the attending preferably before they sign AMA. I have been involved in cases like this and you see how they can rip you apart if you don't cover al bases. Basically you have to paint a picture of the patients behavior for the lawyers/judge/jury who weren't there. Hope this helps!

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I'm not an expert in this by any means. With that said, I am not sure that quoting or documenting much of what you are asking people to, will change anything. It is more important to explain your belief that the patient has the capacity to make such a decision, that they are aware of the risks and benefits of such decision and able to repeat them in their own words, that you have offered the next most appropriate therapy or plan, and that they are aware they can always return to the ED without prejudice.

For an attorney to prove malpractice, they have to establish four key things, duty, breach, causation, and damages. Their pulling off their leads etc is not anywhere in these four, and also does not appear in assessment of capacity.

docBChronically painfulModerator EmeritusLifetime Donor10+ Year Member

Just for the sake of debate I've always wondered how much of the patient swearing, threatening and just plain being unreasonable to document. My concern has been that you could find yourself in a situation where the eventual plaintiff's atty argues that the patient's irritability and agitation were the result of his disease (hypoxia, hypercapnea, intoxication, delerium, whatever) and that the very fact that he was so unreasonable means that despite his alertness, orientation, understanding of the warnings and so on you should have known he wasn't right and forced him to stay.

There are really only two lines of argument about why we should be liable for a bad outcome in a patient who AMAd: the assertion that we didn't properly explain the risks, alternatives and so on and the assertion that the patient really didn't have capacity tu understand what was going on.

Prior to my later years in residency (ie med school and junior resident), I had always been taught, and maybe blindly followed, that if a person has capacity they can refuse any treatment and must be allowed to AMA, regardless of severity of disease or pending death. However, a few recent conversations with attendings have made me question whether this is just "academics" and not applicable to the private world - or even the "real" world in academics (when lawyers are lurking).

Example case:

45 female, PMHx depression, uncontrolled HIV (that is, non-compliant), severe asthma (yes, noncompliant) - very well-known to all ED staff - usually comes in wheezing crazy loud, gets a few treatments and prednisone and then just disappears about three hours later - but occasionally comes in barely moving air and fails all therapy, gets tubed and abx for some impressive pna

Regardless of disease, she is always nasty to all staff and refuses just about everything except prednisone and enough albuterol to make her ambulatory

last time I saw her she was presenting with another asthma exacerbation - a bit worse than usual, required our "step-down" area (not quite critical care), hypoxic, wheezing, tachypneic, not really pna - hypoxia and RR improved with O2 and albuterol - mental status back to angry but competant

She demanded to leave, as usual. My attending said no way - too sick! to go. It seemed to me that if she made the decision to AMA when not hypoxic and competent (even if requiring O2 to maintain sats and competency), then she should be able to walk out the door...even if it was to die. My attending said I was living in an ivory dreamworld, blinded to the lethal weapon-carrying lawyers.

What do you all think? [please try to keep personal and political opinions out of it]

She demanded to leave, as usual. My attending said no way - too sick! to go. It seemed to me that if she made the decision to AMA when not hypoxic and competent (even if requiring O2 to maintain sats and competency), then she should be able to walk out the door...even if it was to die. My attending said I was living in an ivory dreamworld, blinded to the lethal weapon-carrying lawyers.

What do you all think? [please try to keep personal and political opinions out of it]

HH

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I think your attending is likely correct. But I have a question about the flip side. Say you restrain her (physically or chemically) so that you can treat her appropriately (nebs, roids, plastic cigar and Mr. Lung, whatever), what's to keep her from going to an attorney and getting him/her to file some sort of abuse/malpractice/wrongful imprisonment type of suit?

I personally (with extremely minimal knowledge of medmal issues) think that you'd probably be OK in the latter situation and likely just fine in the former. But something to think about.

I think your attending is likely correct. But I have a question about the flip side. Say you restrain her (physically or chemically) so that you can treat her appropriately (nebs, roids, plastic cigar and Mr. Lung, whatever), what's to keep her from going to an attorney and getting him/her to file some sort of abuse/malpractice/wrongful imprisonment type of suit?

I personally (with extremely minimal knowledge of medmal issues) think that you'd probably be OK in the latter situation and likely just fine in the former. But something to think about.

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Exactly!
I'll reveal what happened with this case later...the medical course is very related to your comments...I'd like to hear a few more opinions before revealing more...
HH

By restraining and treating a competent (albeit stupid and disagreeable) person (even if moribund)- you are making yourself vulnerable for charges of false inprisonment and assault.

A good resource for backup when making decisions to allow someone to leave AMA is the house supervisor (they deal with that situation all the time) and also the quality department- liability stuff is right up their alley.

There is an AMA T-sheet that has check boxes for the relevant parts of the discussion, decision making capacity, and at the end has a place for a patient to sign saying the understand the risks and still want to leave. It includes things like tried to get family, PCP, etc. involved.

I had a woman with a ruptured appy (sent in by NP after pelvic exam and pelvic U/S for r/o uterine fibroid vs. ovarian cyst). She left AMA with PO abx after finding out that the surgeon wasn't going to be doing an appendectomy until her infection had resolved.

I called her the next day to she how she was doing (worse) and talked her into coming back. But you can better believe I would have documented the hell out of that call if she had refused. When you know something bad is going to happen you need to make it crystal clear (in the medical record) that you cared about the patient and did everything short of drugging and strapping down the patient to help them out.

southerndoclife is goodModerator EmeritusLifetime Donor10+ Year Member

It's amazing the number of people who will change their minds when I very bluntly say "I think you're making a stupid decision, but I can't hold you against your will. I need you to sign here so that when you go home and die, your family can't sue me."

When you put it bluntly like that, more than half will change their mind and stay. Yes, it may generate a few complaints, but it won't generate lawsuits.

It's amazing the number of people who will change their minds when I very bluntly say "I think you're making a stupid decision, but I can't hold you against your will. I need you to sign here so that when you go home and die, your family can't sue me."

When you put it bluntly like that, more than half will change their mind and stay. Yes, it may generate a few complaints, but it won't generate lawsuits.

Capacity is a medical assessment related to a single decision and does not reflect a global level of functioning. A patient may have the capacity to decide about sutures, but not on admission at the same time.

The assessment of capacity involves a risk benefit analysis on part of the physician, weighed against the patient's ability to reiterate risks and benefits of the intervention in their own words. Their also should be an understanding of a patient's logic in making the decision they are making. (i.e. afraid of needles, need to go to work, doesn't trust physician etc.)

Competence, is a legal assessment, and thus can only be made by a judge. It relates to a global ability to function and thus places decision making capacity for every decision in a surrogate's hands if the patient is deemed incompetent in court.

I think people often get themselves into trouble by using the terms interchangeably.

Also, please note, that if you are taken to court for placing a patient on an involuntary hold and the patient questions it, this is not part of Tort law. This is important because medical malpractice covers tort law only, not criminal law, where the case of false imprisonment / kidnapping would be covered. Thus, you are not covered under malpractice coverage and a verdict against you carries devestating consequences to your ability to practice medicine.

With that said, if you are acting in the best interest of the patient, you are rarely going to get in trouble like this, but it is an important distinction.

My understanding is that the signed AMA form is nearly useless in protecting physicians.

I ask some to sign the form, but with the more nominal cases that are turning down workup or admission I simply document what I explained to them were the benefits of workup/admission and the risks of not doing this and that they understood the risks they were taking but still wish to decline.

I doubt much of anything we document or get them to sign helps us as much as we'd like. I feel that the AMA forms are somewhat adversarial, in general, without any real added benefit for us.

About a year ago, I had an uppity hospital board member who refused to be admitted to our hospital. She had severe epigastric pain requiring a lot of dilaudid, but had normal vitals, CT and RUQ US. When I tried to admit her and said that I would send her upstairs and the surgeon would see her there (our waiting room was as full as I've ever seen it and I really needed the bed) she got angry and wanted to talk to the surgeon in the ER first and decide whether she needed to be admitted to our hospital or transferred to a bigger hospital where she could get more specialist evaluation. I conceded and said that the surgeon would see her in the ER, but she was too angry for me to talk to, let alone help, and demanded to leave. On her way out, I said that she would have to sign an AMA form, which really made the stuff hit the fan. After several meetings discussing the matter, sitting in the CEO's office on various occasions, being forced to sign an apology letter my boss wrote, and having all my charts reviewed for 6 months, my boss told me to never sign out anyone against medical advice except in extreme circumstances.

I'm not sure where I stand on the issue in general. I haven't signed out someone AMA in a year and a half since then.

I think there are 2 different categories of people that the AMA forms are generally given to.
1. Those patients with possibly severe disease that would be best off in the hospital (hypoxic pneumonias, mild strokes, Chest pain, pyelonephritis, etc.). However, the majority of these patients probably would do as well at home as in the hospital. Basically, you would admit these patients to the floor, or telemetry.
2. Those patients that will likely have great morbidity and are at extreme risk of mortality if not given aggressive in-patient management (heart attacks, major strokes, ruptured viscous, etc.). These patients would likely be admitted to the ICU.

Patients in category one, I document heavily, and ask the nurse to do the same. In category two, I would ask them to sign an AMA form. Making them write out "I understand the above" on the AMA form seems a good idea. It fulfills numerous mini-mental status points (they can understand a command, remember it, follow it, write a sentence, figure out spacial relationships on the paper, etc.)

After several meetings discussing the matter, sitting in the CEO's office on various occasions, being forced to sign an apology letter my boss wrote, and having all my charts reviewed for 6 months

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Unless you're a partner (unlikely, considering the details), or make such a good amount of money that you can salve your wounds, this sounds like quite an uninviting place to work. You weren't wrong, and had to eat one big **** sandwich.

I'm not an expert in this by any means. With that said, I am not sure that quoting or documenting much of what you are asking people to, will change anything. It is more important to explain your belief that the patient has the capacity to make such a decision, that they are aware of the risks and benefits of such decision and able to repeat them in their own words, that you have offered the next most appropriate therapy or plan, and that they are aware they can always return to the ED without prejudice.

For an attorney to prove malpractice, they have to establish four key things, duty, breach, causation, and damages. Their pulling off their leads etc is not anywhere in these four, and also does not appear in assessment of capacity.

Again, I'm not an expert in this arena, but have a personal interest.

Sincerely,
TL

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I respect your input, and I am no expert either, but I have been to 2 depositions and called to risk management on cases like this before. I always make sure that my documentation reflects the MD's so that I am protecting us both in case this goes to court. Make sure your nurses are doing that with you because if the chart is reviewed, they will compare the nurses note with the MD's note and if they are different, they will assume one of us is trying to hide something.

The reason why I say to document this, is because we are documenting objectively the behavior it may protect us from the patient lying and accusing the big bad MD "made him" sign himself out. Think of it this way. When you go to court, they blow up your note on a big screen in front of jurors.

Forget about your education and training for a minute and pretend you are Joe Plumber or Suzy Homemaker who thinks that the rich doctors are kicking patients out of the hospital because this Jerry Springer guest lookalike suing you has no insurance. I am not in any way trying to criticize or be disrespectful in any way, just trying to give you another perspective.

The lawyer may argue that this guy was so sick that he didn't know what he was doing and didn't really want to leave the hospital but you "forced" him to write that and leave. Doing the note my way, I think, will help convince a judge to throw the case out before it even gets to a trial where the 4 criteria are needed

Dr. Thymeless note in your fashion: Patient wants to sign out AMA. Told of all risks and to come back to ED if chest pain returns. Given AMA form to sign on which the patient writes I understand all risks. Patient A+O x 3, not intoxicated and mentally competent.

Dr. Thymeless note my way: Went to bedside to discuss plan of care with patient, patient disagrees with recommendations and wants to sign AMA. Patient given the opportunity to ask questions (and offered alternatives when appropriate) which he refuses. Patient states in loud voice using angry tone "I need to get home to watch the football game I thought I would be out of here by now! I'll see my own doctor tomorrow I don't need to stay here!" Risks of signing AMA including death, explained to patient and wife. Both patient and wife state understanding of these risks. Patient signed AMA with nurse jane and wife as witnesses. Patient generally well appearing, appears in no distress, denies having chest pain at this time. Patient seen walking outside of ED doors to smoke several times during ED stay. (If you think this guy is going to be trouble, I would document this before you even get the AMA part) Pt instructed to follow up with PMD, given rx's for XYZ, referral to cardiologist, and instructed to return to ER for any chest pain/discomfort, difficulty breathing, or for any other concerns. While walking out of ER, wife states to me "I am going to sue you people and get rich, I'm going to call that lawyer on TV!".

If the patient is in the ER alone, I would make my best effort to get the PMD or a family member on the phone to try to convince the patient the stay and document this. In peds, AMA is a horse of a different color. In my experience we do not allow parents to sign AMA especially if the child is sick. We have called the police before if a parent elopes with a sick child.

Hopes this helps some! Great discussion. Its sad we have to do this, people should be responsible for their own actions!!!

Just out of curiousity, sign my experience with this is minimal (n=2 or 3), but what is the success rate for avoiding a pt signing out AMA altogether by saying that doing so likely means that insurance won't cover any of their visit and they will have to pay the bill themselves?

Just out of curiousity, sign my experience with this is minimal (n=2 or 3), but what is the success rate for avoiding a pt signing out AMA altogether by saying that doing so likely means that insurance won't cover any of their visit and they will have to pay the bill themselves?

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I don't use that line because it isn't true - why should we not be paid by insurance for work that has been done when the patient decides they don't want more? It's a myth that AMA visits become a pt's responsibility. Most insurance companies and Medicare/MedicAid retain the right to refuse payment, but making it actually happen is a different thing.

docBChronically painfulModerator EmeritusLifetime Donor10+ Year Member

Just out of curiousity, sign my experience with this is minimal (n=2 or 3), but what is the success rate for avoiding a pt signing out AMA altogether by saying that doing so likely means that insurance won't cover any of their visit and they will have to pay the bill themselves?

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I agree with Apollyon that this is more myth than fact. My billing company confirmed that this was not true years ago which surprised us. Now all of the nurses where I work think it is absolutely true and they try to use it to stop AMAs all the time. It is variably successful.

I have had people I know go to the ER who were triaged but left before being seen by MD and the insurance refused to pay. These people had private insurance, maybe that makes a difference? I use this line too, and it usually works.

I respect your input, and I am no expert either, but I have been to 2 depositions and called to risk management on cases like this before. I always make sure that my documentation reflects the MD's so that I am protecting us both in case this goes to court. Make sure your nurses are doing that with you because if the chart is reviewed, they will compare the nurses note with the MD's note and if they are different, they will assume one of us is trying to hide something.

The reason why I say to document this, is because we are documenting objectively the behavior it may protect us from the patient lying and accusing the big bad MD "made him" sign himself out. Think of it this way. When you go to court, they blow up your note on a big screen in front of jurors.

Forget about your education and training for a minute and pretend you are Joe Plumber or Suzy Homemaker who thinks that the rich doctors are kicking patients out of the hospital because this Jerry Springer guest lookalike suing you has no insurance. I am not in any way trying to criticize or be disrespectful in any way, just trying to give you another perspective.

The lawyer may argue that this guy was so sick that he didn't know what he was doing and didn't really want to leave the hospital but you "forced" him to write that and leave. Doing the note my way, I think, will help convince a judge to throw the case out before it even gets to a trial where the 4 criteria are needed

Dr. Thymeless note in your fashion: Patient wants to sign out AMA. Told of all risks and to come back to ED if chest pain returns. Given AMA form to sign on which the patient writes I understand all risks. Patient A+O x 3, not intoxicated and mentally competent.

Dr. Thymeless note my way: Went to bedside to discuss plan of care with patient, patient disagrees with recommendations and wants to sign AMA. Patient given the opportunity to ask questions (and offered alternatives when appropriate) which he refuses. Patient states in loud voice using angry tone "I need to get home to watch the football game I thought I would be out of here by now! I'll see my own doctor tomorrow I don't need to stay here!" Risks of signing AMA including death, explained to patient and wife. Both patient and wife state understanding of these risks. Patient signed AMA with nurse jane and wife as witnesses. Patient generally well appearing, appears in no distress, denies having chest pain at this time. Patient seen walking outside of ED doors to smoke several times during ED stay. (If you think this guy is going to be trouble, I would document this before you even get the AMA part) Pt instructed to follow up with PMD, given rx's for XYZ, referral to cardiologist, and instructed to return to ER for any chest pain/discomfort, difficulty breathing, or for any other concerns. While walking out of ER, wife states to me "I am going to sue you people and get rich, I'm going to call that lawyer on TV!".

If the patient is in the ER alone, I would make my best effort to get the PMD or a family member on the phone to try to convince the patient the stay and document this. In peds, AMA is a horse of a different color. In my experience we do not allow parents to sign AMA especially if the child is sick. We have called the police before if a parent elopes with a sick child.

Hopes this helps some! Great discussion. Its sad we have to do this, people should be responsible for their own actions!!!

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Hmm....maybe you misunderstand what my documentation involves...it might look more like this...

Mr. John Doe has a history and examination that is suspiscious for an acute coronary syndrome. I am concerned that given his ecg changes and troponin elevation that he would be better served being admitted to the hospital under the care of our cardiologists, but he is declining. We, the patient, his wife, and I discussed that although admission involves more time away from home, as he wishes to return home and watch football, there is the chance that his condition could cause him long term disability or even death. We discussed that admission and evaluation by a specialist may be able to avert these outcomes and he was able to reiterate these risks of impairment and death in his own words. Mr. Doe suggests that he would like to see his own physician tomorrow and I think this is a viable, albeit inferior, alternative. At this time, Mr. Doe is not holdable as he is able to reiterate the sitautional risks and benefits back to me. Mr. Doe and his wife are aware that should they need further help, or change their mind about admission they can always return to the Emergency Department for reevaluation without any prejudice. This discussion involved our nursing staff, the patient, his wife, and myself.

So in the end they are very similar pieces of documentation, but are separated by the lack of unnecessary details. The tone of the patient's voice may only serve to distract from the fact that the patient is able to make the decision. The dramatics take away from the key facts which are the patient is aware of the potential effects of their decision and you, and the relevent parties have discussed them in depth. At this time you have no further recourse but to allow them to decline your intervention.

Regardless, we may have to agree to disagree on the utility of such details. Thank you for your presumption of what my documentation may look like by the way, it was not my impression to imply that an AMA discussion should look so standardized. Please note that I do encourage detail, but only detail that is relevent to the key medical and legal issues at play.

Remember, an AMA discussion does not have to be adversarial and in fact is simply a statement of disagreement. (Ironically, similar to our differing views on this documentation) The addition of some of the details you included does not imply that the patient has decision making capacity, and in fact may imply that they are too emotional or too much in need of a cigarette to make a clear and thoughtful decision. For example, the statments you have listed above actually are similar to the things that intoxicated patients comign to my ED say...many of whom do not have the capacity to refuse certain treatments I am suggesting for them. The tone of voice being angry also implies that there is conflict between you and the patient...all of these issues take away from the point: the patient is able to make the choice, and you cannot force them to agree with you.

The best things are concise, complete, and accurate.

Cheers,
TL

P.S. I agree about the misconception that AMA implies lack of insurance reimbursement. One of my colleagues looked into this as a quality improvement measure and found all but one insurance agency to pay for these. The one outlier simply didnt respond to the request so we are unsure of their stand.

I used to just document & skip the form for most cases. When I asked a medmal lawyer which he thought was more important he said "both". His reasoning wasn't much more than saying "I could help, so why not?". Now I'm back to getting the form signed in most cases. Of note, however, when I got a call from the dean of our med school asking me to take special care of a big benefactor and he ended up wanting to leave AMA I just documented the crap out of it and skipped the AMA form.

I always make sure that my documentation reflects the MD's so that I am protecting us both in case this goes to court. Make sure your nurses are doing that with you because if the chart is reviewed, they will compare the nurses note with the MD's note and if they are different, they will assume one of us is trying to hide something.

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I think this is very important, both in the context of AMA and in general. Communicate with the rest of the staff and make sure you're all on the same page.

It's amazing the number of people who will change their minds when I very bluntly say "I think you're making a stupid decision, but I can't hold you against your will. I need you to sign here so that when you go home and die, your family can't sue me."

When you put it bluntly like that, more than half will change their mind and stay. Yes, it may generate a few complaints, but it won't generate lawsuits.

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I do something similar. In addition, My mentor types out in large font "I understand that by refusing [xyz] I could die." That gets printed and the patient is asked to sign, then it ends up on the chart. I have no idea if this does anything legally, but I've seen it change a few minds.

I thank all of you for your valuable insight. It's nice when we can have a civilized discussion and can see things from anothers perspective.

Thymeless, I did not mean in any way that your note was ineffective or that you only write one like and that was it. I hope you did not take it in a way that I meant you personally were not writing notes with enough detail. I have learned a lot reading this thread from what it is like on the other side.

The attendings I work with in the ER often do document statements and threats the patient make in their progress notes. I assumed that it was common practice, but as I see here, everyone really does have a different way of doing things. I think its wonderful that we can give each other suggestions, I just think its sad that we have to do this in the first place when patients cannot take responsibility for themselves.

What I learned from this topic is that although MD and nursing notes have similar aspects such as the SOAP format, the progress notes are much different than I expected them to be. In nursing school, we are often encouraged to document patient statements in quotes to protect ourselves and emotional states along with the facts. I appreciate the critique of my note, and I have learned how things that would protect me could possibly set you up for more trouble if that same note was written by the attending. I was involved in a case where the patient had a wrong side procedure done (not surgery) and I documented how the patient was refusing to hang up and talking on her cell phone during the procedure. Because of this statement as well as other subjective info, they were able to use my nursing note without any real further questioning at the lawyers office. I'm sure though, that even though I may get off because of my notes, its not going to be as easy for you guys.

I'm glad we agree that our notes need to reflect each other. In my experience, although as you all have stated, that note would be inappropriate for an MD, the note would be appropriate for an RN to protect herself and you. Since the attending is the one most responsible for the care, your focus would be to do what you can to ensure the patient is leaving as safe as could be expected when signing AMA. With the nice notes you have all written here, if I write a note that is describing how angry the patient is it would help a jury or judge see the picture of how the patient was acting without putting you in jeapordy.

In reality, when patients come in that we both know are going to be trouble, I take the MD's lead on what to include in my note so that we are on the same page. The heat will come down more on you than on me, so I would never want to write something that would get you into trouble.

southerndoclife is goodModerator EmeritusLifetime Donor10+ Year Member

One of the biggest things to do in AMA patients is to treat them the best you can as an outpatient. Refusing admission, inpatient treatment, diagnostic procedures, etc. does not relieve you of treating them all together.

Case in point: patient with diverticulitis with microperforation and abscess. Patient refused admission. I wrote for pain meds and antibiotics for patient to go home with after signing out AMA. The nurse asked me why I did that, and why I insisted she give the patient discharge instructions on when to return (fever, worsening pain, or if he changes his mind about admission).

If the patient goes home and crumps, if you did nothing, one will ask why you didn't at least try. The patient didn't refuse to take antibiotics (if he did, he simply wouldn't fill the script - at least offer it to him). He didn't refuse all medical treatment, but only certain aspects of it.

So if you AMA someone and don't treat them as best you can given the circumstances, you may subject yourself to huge liability if the patient goes home and gets septic. (This patient went home, got septic, returned, had a large perforation, and died intraoperatively... lactate of 21 upon admission.) The patient's wife was understanding when I saw him the second time. "You told him the antibiotics wouldn't work, but at least you tried. I'm sorry he was so difficult for you to deal with."

One of the biggest things to do in AMA patients is to treat them the best you can as an outpatient. Refusing admission, inpatient treatment, diagnostic procedures, etc. does not relieve you of treating them all together.

Case in point: patient with diverticulitis with microperforation and abscess. Patient refused admission. I wrote for pain meds and antibiotics for patient to go home with after signing out AMA. The nurse asked me why I did that, and why I insisted she give the patient discharge instructions on when to return (fever, worsening pain, or if he changes his mind about admission).

If the patient goes home and crumps, if you did nothing, one will ask why you didn't at least try. The patient didn't refuse to take antibiotics (if he did, he simply wouldn't fill the script - at least offer it to him). He didn't refuse all medical treatment, but only certain aspects of it.

So if you AMA someone and don't treat them as best you can given the circumstances, you may subject yourself to huge liability if the patient goes home and gets septic. (This patient went home, got septic, returned, had a large perforation, and died intraoperatively... lactate of 21 upon admission.) The patient's wife was understanding when I saw him the second time. "You told him the antibiotics wouldn't work, but at least you tried. I'm sorry he was so difficult for you to deal with."

One of the biggest things to do in AMA patients is to treat them the best you can as an outpatient.

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I'm not an expert in this, however I'm not sure I can completely concur with this. I have been taught that prescribing medications may be viewed as condoning or supporting the decision to leave, and may make a tort charge less defensible.

I'm not an expert in this, however I'm not sure I can completely concur with this. I have been taught that prescribing medications may be viewed as condoning or supporting the decision to leave, and may make a tort charge less defensible.

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This is absolutely the standard of care, and failure to provide a "second best" therapy or intervention is considered malpractice if a bad outcome is to occur.

I'm not an expert in this, however I'm not sure I can completely concur with this. I have been taught that prescribing medications may be viewed as condoning or supporting the decision to leave, and may make a tort charge less defensible.

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I see how someone would think that what you are saying is true, but Thymeless is 100% correct. If a patient signs AMA you must give them any RX's, d/c instructions just the same as if you are d/cing them home. If you don't they can sue you. You must make your best effort to ensure that they are leaving the hospital with what they may need under the circumstances.

I agree with Apollyon that this is more myth than fact. My billing company confirmed that this was not true years ago which surprised us. Now all of the nurses where I work think it is absolutely true and they try to use it to stop AMAs all the time. It is variably successful.

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Yep, it's myth, and they could make a case for coercion if the nurses throw that around.

Yep, it's myth, and they could make a case for coercion if the nurses throw that around.

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Possibly. I do know that if a patient is triaged, has not yet been seen by the MD, if they walk out they will be billed a few hundred just for registering and insurance won't pay it. The patient does not have to sign AMA if they elope before MD evaluation.

Possibly. I do know that if a patient is triaged, has not yet been seen by the MD, if they walk out they will be billed a few hundred just for registering and insurance won't pay it. The patient does not have to sign AMA if they elope before MD evaluation.

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The patient does not "have" to do anything. They can refuse to sign the AMA if they want. When a patient elopes I always document: "Patient left the department before I had a chance to re-examine the patient and discuss his medical condition or give him any discharge instructions/medications"

The patient does not "have" to do anything. They can refuse to sign the AMA if they want. When a patient elopes I always document: "Patient left the department before I had a chance to re-examine the patient and discuss his medical condition or give him any discharge instructions/medications"

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The way it was explained to me was that if the patient is triaged and leaves BEFORE any MD evaluation, that is not the same thing as AMA because they haven't recieved any "medical advice". According to EMTALA, triage does not meet the criteria for a medical screening exam, so they haven't been "evaluated" yet. If I run into anyone I know from risk management, I'll ask so we know for sure.

docBChronically painfulModerator EmeritusLifetime Donor10+ Year Member

The way it was explained to me was that if the patient is triaged and leaves BEFORE any MD evaluation, that is not the same thing as AMA because they haven't recieved any "medical advice". According to EMTALA, triage does not meet the criteria for a medical screening exam, so they haven't been "evaluated" yet. If I run into anyone I know from risk management, I'll ask so we know for sure.

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I agree that a patient who has not been seen is really a "left after triage" and not an AMA although many nurses would have that patient sign the AMA form under the idea that the nurse advised the patient to stay and they didn't. I frequently run into the situation where a patient suddenly decides to elope in the middle of a work up and the nurse comes to me and says "the patient left but I got him to sign the AMA form." That's not really appropriate because I haven't really advised the patient about the dangers of leaving because I didn't know he was going to go. In that case it's probably more appropriate to not have them sign AMA and list them as an eloped. The hospitals and their employees often want to direct the liabiliy toward the doc and the docs tend to want to limit that.

southerndoclife is goodModerator EmeritusLifetime Donor10+ Year Member

I'm no EMTALA expert, but it's my understanding that this is up to the states to decide based upon nursing abilities by law.

For example, this is from the Texas Nursing Board:

Question 1: Can a RN Perform A Medical Screening Exam?

The EMTALA guidelines and frequently asked questions (FAQs) indicate that a facility may credential specific registered nurses and develop bylaws specifying which RN nursing staff is considered to be "qualified medical personnel" and under what circumstances a physician must be consulted and/or must physically come to the unit/facility. In addition to being permitted by an employing facility, however, the RN must also be competent to carry out the assigned task in a manner that complies with the NPA and board Rules.

A RN may be able to perform a medical screening exam if he/she possesses adequate knowledge and skills and there are adequate support systems and standing orders in place; however, the RN should always have telephonic access to a physician who is also capable of physically responding to do a hands-on evaluation if needed or requested by the RN. RNs who do not hold advanced practice authorization cannot independently engage in medical diagnosis or prescription of therapeutic or corrective measures, as this is beyond the scope of practice for a RN.

although many nurses would have that patient sign the AMA form under the idea that the nurse advised the patient to stay and they didn't. I frequently run into the situation where a patient suddenly decides to elope in the middle of a work up and the nurse comes to me and says "the patient left but I got him to sign the AMA form."

WHAT?????

I'll get that consent for your central line and the blood transfusion while I'm at it!!

Holy Illegal. I can't even believe they would think to do something like this! A nurse cannot obtain consent of any kind. That is nursing 101. Nurses witness consent, we don't obtain it. AMA is on the level of consent since they are agreeing to leave against medical (MD) advice. They could lose their license for this.

They should be informing you that the patient eloped, and you both document that the patient walked out before dispo/evaluation. End of story. If I were you, I would make sure this practice stops today. Are they putting your name down on the form? I certainly hope not!

As far as the laws allowing nurses to do a medical screening exam, I don't see how any hospital policy would even allow this. Even if they did, I'm not gonna get sued if someone comes in c/o toe pain and then walks out and has an MI 2 hours later. No thank you!

docBChronically painfulModerator EmeritusLifetime Donor10+ Year Member

They should be informing you that the patient eloped, and you both document that the patient walked out before dispo/evaluation. End of story. If I were you, I would make sure this practice stops today. Are they putting your name down on the form? I certainly hope not!

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Today being the day that it happened twice. It really is a daily occurence around here. Trying to stop it would be just as futile as trying to get the nurses to stop demanding that I treat asymptomatic hypertension. They don't usually write my name on the form. They just write the dreaded "Doctor aware." on their notes.

Today being the day that it happened twice. It really is a daily occurence around here. Trying to stop it would be just as futile as trying to get the nurses to stop demanding that I treat asymptomatic hypertension. They don't usually write my name on the form. They just write the dreaded "Doctor aware." on their notes.

Today being the day that it happened twice. It really is a daily occurence around here. Trying to stop it would be just as futile as trying to get the nurses to stop demanding that I treat asymptomatic hypertension. They don't usually write my name on the form. They just write the dreaded "Doctor aware." on their notes.

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I would go straight to risk management and let them know what is going on. AMA is in fact a form of consent as you know, and it is ILLEGAL in all 50 states for a nurse to obtain consent. I wonder what kind of bind it puts you in when they write MD aware and you are the MD they are referring to, even if your name isn't on there? These nurses can lose their license for obtaining an AMA signature if something were to happen. I certainly hope that they are able to recognize who shouldn't be allowed to leave AMA.

If the patient has been seen by you and they want to leave AMA, they have to be told to wait until you are available to sign them out. If they refuse to wait, than they are supposed to document that the patient eloped or refused to be given AMA instructions/aftercare by MD.

If the patient has never been seen by you, there is no patient-phyisican relationship, and there is no need for an AMA form.

God, now I know why there are so many nurse haters on this forum. Where do they get these nurses from??

I would go straight to risk management and let them know what is going on. AMA is in fact a form of consent as you know, and it is ILLEGAL in all 50 states for a nurse to obtain consent. I wonder what kind of bind it puts you in when they write MD aware and you are the MD they are referring to, even if your name isn't on there? These nurses can lose their license for obtaining an AMA signature if something were to happen. I certainly hope that they are able to recognize who shouldn't be allowed to leave AMA.

If the patient has been seen by you and they want to leave AMA, they have to be told to wait until you are available to sign them out. If they refuse to wait, than they are supposed to document that the patient eloped or refused to be given AMA instructions/aftercare by MD.

If the patient has never been seen by you, there is no patient-phyisican relationship, and there is no need for an AMA form.

God, now I know why there are so many nurse haters on this forum. Where do they get these nurses from??

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Just a couple thoughts...

1. Everyone should obtain consent for things they do...in other words, nurses should obtain consent before starting IVs, foleys, etc. It is not illegal to have a discussion about consent on the part of anyone doing anything to someone else...

2. The moment a patient registers, the duty to the patient has been established by the physician. The physician is responsible for it all...from the moment a patient is registered. It can be even in the prehospital setting if the physician is acting as medical control.

southerndoclife is goodModerator EmeritusLifetime Donor10+ Year Member

...as futile as trying to get the nurses to stop demanding that I treat asymptomatic hypertension.

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I'm glad someone else has this problem. I swear the patients in my county just sit around all day long checking their blood pressure every 10 minutes, and when it gets >160/100 they come to the ER. No symptoms. They just want it lowered, and get all huffy when you tell them that rapidly lowering it could increase their risk of stroke.

There was one shift where I saw 6 such patients and thought I was going to need some Geodon to continue my shift.

1. Everyone should obtain consent for things they do...in other words, nurses should obtain consent before starting IVs, foleys, etc. It is not illegal to have a discussion about consent on the part of anyone doing anything to someone else...

2. The moment a patient registers, the duty to the patient has been established by the physician. The physician is responsible for it all...from the moment a patient is registered. It can be even in the prehospital setting if the physician is acting as medical control.

Just my $0.02

TL

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Of course the patient has to agree to care, but consent to things that require an MD to do such as surgical consent, consent for IV contrast, invasive or risky procedures and AMA, cannot be done by an RN. That is straight up illegal.

Creating the Relationship​

The physician-patient relationship is
created by mutual consent that may
be express or implied. For example,
an unconscious accident victim who
is brought to the emergency room
is not knowingly seeking the
services of a physician. Yet, the
relationship is created when the ER
doctor begins treatment. Mutual
consent is implied in this case.
Simply making an appointment for
the first time with a physician is not
usually sufficient to create the
relationship, even though there may
be mutual consent evidenced by
the patient making the appointment
and the physician scheduling it.
Generally, the duties and
obligations created by the
relationship do not arise until the
physician affirmatively undertakes
to diagnose and treat the patient, or
affirmatively participates in the
diagnosis and treatment. However,
an informal opinion (a curbside
consultation) offered to a colleague
regarding patient care does not
create a physician-patient​

Of course the patient has to agree to care, but consent to things that require an MD to do such as surgical consent, consent for IV contrast, invasive or risky procedures and AMA, cannot be done by an RN. That is straight up illegal.

Creating the Relationship​

The physician-patient relationship is
created by mutual consent that may
be express or implied. For example,
an unconscious accident victim who
is brought to the emergency room
is not "knowingly" seeking the
services of a physician. Yet, the
relationship is created when the ER
doctor begins treatment. Mutual
consent is implied in this case.
Simply making an appointment for
the first time with a physician is not
usually sufficient to create the
relationship, even though there may
be mutual consent evidenced by
the patient making the appointment
and the physician scheduling it.
Generally, the duties and
obligations created by the
relationship do not arise until the
physician affirmatively undertakes
to diagnose and treat the patient, or
affirmatively participates in the
diagnosis and treatment. However,
an informal opinion (a curbside
consultation) offered to a colleague
regarding patient care does not
create a physician-patient​

relationship in most jurisdictions.

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Dear NYRN,

I'm not sure where your citation is from, but please refer to Emergency Physicians Monthly April 7, 2010. There is a discussion by William Sullivan, MD, JD about EP Duty. I assure you that if a patient comes to the ED and registers, but is not seen and dies in the waiting room...all eyes will be on the ED staff because there IS a duty to the patients even in the waiting room. This exact issue presented in NY itself and made national headlines when a patient was found on video to have died in the waiting room without receiving adequate assessments by ED staff passing by. Although the physician was not aware of the situation at all and had not even seen the patient, the duty was established already. Dr / Attorney Sullivan outlines how each case is unique and to believe absolute truths (i.e. duty cannot be established before being seen by the physician), might leave you surprised in an unfortunate way...

I also checked with our legal department here at Mayo Clinic who confirm that duty can be established even in the prehospital setting, but is highly likely to be legally established upon the patient entering and registering.

Also, as I was reading your citation closer, it notes that, "generally, the duties and obligations created by the relationship do not arise until the physician affirmatively undertakes to diagnose and treat the patient," this has been done in the ED when the patient registers...because, as you are aware we are required to perform a medical screening examination on anyone who registers to be seen.

The information about appointments are more appllicable to an outpatient office setting, but even there it suggests that duty can be established upon the physician scheduling the patient to be seen. This is partly, why nearly every medical establishment has the information about "if this is a life threatening emergency, please hang up the phone and call 911", because by the act of the patient calling your outpatient office (I learned from my parents who had outpatient practices), there is some duty established.

As for consent, no one should get consent for something they themselves are not performing, so the ED RN should not obtain consent for contrast, surgery, etc. Our Radiology contrast infusion RNs do obtain consent for contrast. Some of our other specialty nurses who perform actions that require consent, do obtain consent for that procedure (ex, our PICC RNs get consent for PICC placement).

This also applies to physicians; I as the ED doc will not consent someone for an appendectomy as I will not perform it. I do obtain consent for non emergent procedures that I myself will perform.

There are legal and EMTALA exceptions that allow certain locations to have nurses perform medical screening examinations. If a hospital system has established that an RN will perform all medical screening examinations (which is done in some places as noted above), then they can discuss AMA issues with the patient as well. This is because, as you point out AMA is in essence refusal of consent for something.

The take home...medicolegal issues are extremely complex, and are location dependent. To provide the safest care for both the patients welfare and the staff's legal protection, assume that duty to the patient is established early, anyone can discuss consent for procedures or interventions they themselves will perform, anyone can discuss AMA issues.

Everyone's actions are ultimately the responsibility of the attending physician responsible for the ED during the time the issue arises.

I'm glad someone else has this problem. I swear the patients in my county just sit around all day long checking their blood pressure every 10 minutes, and when it gets >160/100 they come to the ER. No symptoms. They just want it lowered, and get all huffy when you tell them that rapidly lowering it could increase their risk of stroke.

There was one shift where I saw 6 such patients and thought I was going to need some Geodon to continue my shift.

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At least its asymptomatic hypertension. We have a dedicated population of free range elderly that will attribute all sorts of vague neuro symptoms (especially blurred vision NOS and dizziness NOS) to their BP. I can feel my soul being sucked out as I try and decipher whether they're genuinely sick or they just wanted to feel like someone cares about them.

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